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0 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT XUDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />16 -373- <br />Project Contact & Telephone # Veronica Freitas 916 -373- <br />A <br />A <br />C <br />Facility Name Quik Stop #125 <br />Phone#209-599-4261 <br />I <br />L <br />Address 1580 W. Main Street, Ripon, CA 95366 <br />TCross <br />Street Jack Tone Road <br />Y <br />Owner/Operator Quik Stop Markets, Inc. <br />Phone#510-657-8500 <br />c <br />Contractor Name Walton Engineering, Inc. <br />Phone# 916-373-1166 <br />N <br />T <br />Contractor Address P.O. Box 1025 W. Sacramento, C <br />CA Lic # 6172 3 8 Class AB Haz <br />A <br />Insurer praetorian Insurance <br />Work Comp #QWC4 000674 <br />T <br />ICC Technician's Name see attached <br />Expiration Date <br />Q <br />R <br />ICC Installer's Name see attached <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC M, etc.) <br />Installed <br />T <br />no change <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />A� <br />Plan Reviewers Name Date -71 111 1 -- <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature Aalae4l, Title C n CN Date 1 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME Walton Engineering, Inc. TITLE Contractor PHONE# 916-373-1167 <br />P.O. Box 1025, West Sacramento, CA 95691-1025 <br />SIGNATU <br />EH230038 (revised 08/1/11) <br />2 <br />TE 6/27/2012 <br />.166 <br />